Leigh Turner IJHS 2010

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Globalization and Medical Care

MEDICALTOURISM AND THE GLOBAL

MARKETPLACE IN HEALTH SERVICES:

U.S. PATIENTS, INTERNATIONAL HOSPITALS, AND

THE SEARCH FOR AFFORDABLEHEALTHCARE

Leigh Turner

Health services are now advertised in a global marketplace. Hip and

knee replacements, ophthalmologic procedures, cosmetic surgery, cardiac

care, organ transplants, and stem cell injections are all available for purchase

in the global health services marketplace. Medical tourism companies

market sun and surgery packages and arrange care at international

hospitals in Costa Rica, India, Mexico, Singapore, Thailand, and other

destination nations. Just as automobile manufacturing and textile production

moved outside the United States, American patients are offshoring them-

selves to facilities that use low labor costs to gain competitive advantage

in the marketplace. Proponents of medical tourism argue that a global

market in health services will promote consumer choice, foster competi-

tion among hospitals, and enable customers to purchase high-quality care

at medical facilities around the world. Skeptics raise concerns aboutquality of care and patient safety, information disclosure to patients, legal

redress when patients are harmed while receiving care at international

hospitals, and harms to public health care systems in destination nations.

The emergence of a global market in health services will have profound

consequences for health insurance, delivery of health services, patient-

physician relationships, publicly funded health care, and the spread of

medical consumerism.

Medical brokerages and international hospitals marketing medical tourism

packages first attracted customers by selling inexpensive face lifts, tummy

International Journal of Health Services, Volume 40, Number 3, Pages 443467, 2010

2010, Baywood Publishing Co., Inc.

doi: 10.2190/HS.40.3.d

http://baywood.com

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tucks, breast implants, liposuction, and other forms of cosmetic surgery. They

targeted price-conscious customers wanting procedures not covered under

private health insurance or publicly funded health plans. Purchasers could

lower their out-of-pocket costs by comparison shopping and finding low-cost

medical procedures. Some companies promoted discount surgery or first

world health care at third world prices. Typical advertising pitches featured

surf and surgery holidays in Thailand and surgeon and safari trips to

South Africa. Health care was packaged together with more commonplace

tourist attractions. Marketing executives proclaimed that their goal was to put

the hospital back in hospitality. Though brokerages and destination hospitals

still advertise cosmetic surgery bargains, they now sell a wide array of services

to a much broader clientele. Medical tourism is promoted as a solution to the

high price of medical care in the United States, as well as treatment delays incountries with publicly funded health care. In Canada, the United Kingdom,

and other countries with publicly funded health care programs, medical

brokerages attract customers tired of waiting for hip and knee replacements,

cataract surgery, and other procedures. In Canada, for example, such businesses

as Speedy Surgery and Timely Medical Alternatives solicit clients able to

afford purchase of expedited care. The United States provides a different

and potentially much broader customer base for medical brokerages and

international hospitals. It offers a large population of individuals lacking

health insurance, with limited economic resources, and needing access to

treatment for medically necessary care rather than cosmetic procedures. The

rapid proliferation of medical tourism companies in the United States is pre-

sumably connected to the number of Americans unable to obtain health insurance

or affordable access to local health care facilities. Even medical tourism com-

panies based in Canada attempt to tap into the large market of uninsured and

underinsured Americans seeking access to health care at medical facilities

outside the United States.

Marketing campaigns promoting medical tourism try to link health care

to adventure, relaxation, and holiday fun (13). The reality of international

health-related travel is often quite different from the images of enticing

beaches, romantic settings, and exotic resorts posted on many medical

tourism company websites. In the United States, popularization of medical

tourism is related to social inequalities, loss of employer-provided health

insurance, rising premiums for health insurance, limited public funding

of health care, and lack of access to affordable health care. Many factors

contribute to the high cost of care in the United States, but the low salariesof local health care workers make facilities in such countries as India

and Thailand far less expensive than hospitals in the United States.

Medical tourism reveals the shape that medicine takes when it is com-

modified, subjected to international competition, and subsumed within a global

market economy.

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UNINSURED IN AMERICA

In 2006, 47 million individuals in the United States lacked health insurance (4).

In low-wage sectors of the U.S. workforce, more than 75 percent of employees

decline health insurance (5). They cannot afford health insurance premiums;

their earnings go to cover the cost of immediate needs such as food and shelter.

As employers reduce benefits and cut health plans, increasing numbers of

middle-class Americans are losing employer-provided health insurance. Tattered

social safety nets leave many Americans without access to publicly funded

care. Forced to use personal savings, tap lines of credit, or go into debt to cover

the cost of medical care, growing numbers of Americans are entering the global

marketplace and trying to find care they can afford.

The high cost of health care in the United States drives many low-incomeand middle-class Americans with serious health problems into bankruptcy (6).

Short of outright bankruptcy, medical debt is a risk factor for being unable

to gain access to treatment (7). As medical bills accumulate, sick individuals

lose access to health care providers and health care facilities. Some caregivers

refuse to provide treatment until patients pay their bills and clear their debts.

In other instances, whether out of embarrassment, a sense of stigmatization,

fear of legal action or attracting the attention of debt collectors, or other factors,

many patients avoid seeking medically necessary care because of their unpaid

medical bills.

Denial of coverage on the basis of preexisting conditions means that indi-

viduals who can afford to purchase health insurance are often unable to gain

access to coverage for the medical interventions they are most likely to need.

Inclusion of coverage for these procedures can generate premiums exceeding$2,500 per month. High deductibles and co-payments mean that even individuals

with insurance sometimes cannot afford the medical care they require. Whether

or not they have health insurance, low-income and middle-class Americans with

limited finances are often unable to afford the cost of care at local institutions.

Some Americans living in border states travel to facilities in Mexico or Canada for

medical care. Other citizens fly to India, Thailand, the Philippines, or elsewhere

for comparatively inexpensive health care.

OUTSOURCING EMPLOYMENT

The emergence of international supply chains, the Internet, global telecommuni-

cations, global transportation networks, and interconnected economies has both

pushed and pulled jobs toward regions where workers are paid low wages andhave few benefits (8). Capital flows across borders to regions where goods

and services are produced for the lowest possible costs and sold for maximum

profits. In the United States, this process first affected workers in manufacturing

industries. It then spread through many other sectors of the U.S. economy.

The United States once had a huge textile production industry. Most of those

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jobs were offshored to China, India, Mexico, and Thailand. Back office

administrative work capable of being digitized and electronically transmitted

over the Internet is now done in India. There, lawyers, computer programmers,

accountants, information technology specialists, and call center employees earn

far less than their American counterparts. Jobs related to the health services

industry are also outsourced. Medical transcriptions, accounting, and processing

of insurance claims are all routinely outsourced by U.S. clinics and hospitals

to offshore contractors and subcontractors.

Exploring how offshoring will alter the United States social and economic

fabric, Alan Blinder (8) estimates that 30 to 40 million U.S. jobs could move

to China, India, and other countries. From a global perspective, in some countries

these jobs might improve living standards and help individuals escape from

poverty. In other nations where labor has limited bargaining power, health-related jobs will be accompanied by low wages, nonexistent benefits, and

poor working conditions. For Americans whose health insurance is connected to

their workplace, offshoring of jobs will have profound consequences. As jobs

disappear, employees lose both income and health benefits. Obtaining affordable

health care is a serious challenge for patients purchasing medical interventions

as out-of-pocket personal expenses.

EMPLOYER-PROVIDED HEALTH

INSURANCE

Health benefits constitute a significant expenditure for American employers (9).

To control costs, maximize profits or minimize losses, and make themselves

globally competitive, U.S. companies are cutting or eliminating employee

health benefits (10). Executives threaten to move additional jobs offshore if

unions do not concede reductions in employee benefits. Employees are faced

with a choice: either they agree to wage concessions and benefit reductions or

they risk suffering additional job losses. Workers lose both income and health

insurance as jobs in the United States are outsourced to other countries. A broad

social shift is occurring in which companies are reducing employee benefits

and making saving for retirement and the cost of health care the personal respon -

sibility of individual employees.

To obtain affordable health services, middle-class and low-income Americans

lacking health insurance, paying out-of-pocket, or holding minimalist mini-med

plans offshore themselves by flying to regions where inexpensive health

services are available for purchase (1113). Unable to afford access to localfacilities, they search the global marketplace for less costly treatment.

With its large and growing population of uninsured, underinsured, and people

struggling to pay rising health insurance premiums, the United States is a leading

target market for hospitals seeking international customers. Medical brokerages

are proliferating in the United States as Americans find they must travel to

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purchase affordable health care. These companies both cater to individual clients

and offer packages for employers interested in offering health plans with an

offshore component.

MEDICAL TOURISM BROKERAGES

Medical tourism companies, or medical brokerages, play a crucial role in

advertising and selling health services across a global market. They take clients

from high-cost health care settings, coordinate travel to less expensive health care

facilities, and charge fees for organizing transportation, accommodations, and

treatment. The Internet, inexpensive telecommunications, and economy air travel

all facilitate sending customers to destination hospitals offering low-budget health

care (1, 14). The packages that brokerages market have two important features.Clients must be healthy enough to travel; medical tourism companies do not

advertise emergency medical services. And customers need to see sufficient cost

savings to justify the expense, uncertainty, and inconvenience of travel (15).

Leading medical brokerages in the United States include Planet Hospital,

Global Med Network, World Med Assist, Med Journeys, and Med Retreat.

Some agencies arrange travel to various medical facilities within a single country.

For example, IndUShealth coordinates travel to several hospitals in India.

More commonly, brokerages offer multiple travel destinations and various

price bands or price points for health services. Planet Hospital, a representa-

tive U.S. medical tourism company, sells packages to hospitals and clinics in

Argentina, Belgium, Brazil, Costa Rica, El Salvador, India, Mexico, Panama,

Singapore, Thailand, the United States, and Uruguay. At the top of the price

scale sit underutilized hospitals in the United States. These facilities are willing

to lower the price of care in an attempt to increase patient volume. Customers

able to afford mid-tier rates for treatment often purchase care at private hospitals

in Belgium or Singapore. Clients with limited financial resources typically

select hospitals in India, Malaysia, Mexico, Indonesia, or the Philippines. This

tiered model of pricing is becoming increasingly common as medical tourism

companies recognize that they can grow their customer base by offering dif-

ferent purchase entry points. In contrast, although the strategy developed by

IndUShealth is appropriate for patients willing to consider traveling to India

for treatment, it does not provide options to customers who wish to travel

elsewhere for care. As noted, most companies respond to diverse customer

preferences by offering multiple travel packages.

Because the medical tourism industry is driven by international differencesin the cost of health services, most company websites include charts and graphs

comparing the costs of care at hospitals in various countries. Charts showing

prices for orthopedic procedures and cardiac surgery reveal significant price

differences across countries. Prices in Thailand are often one-third to one-fifth

the cost of treatment at U.S. hospitals. Many Indian hospitals charge one-tenth the



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price of procedures available at U.S. medical facilities. A coronary artery bypass

graft that costs more than $55,000 (U.S. dollars) for insured patients at hospitals

in California can cost $5,000 to $10,000 at hospitals in India (16). Cardiac

procedures priced at $200,000 to uninsured Americans are available for $10,000

in hospitals in India. Marketing initiatives emphasize price differentials and

cost savings obtained by traveling to comparatively inexpensive health care

facilities. Often, charts list how much American patients can save by leaving the

United States and traveling elsewhere for care. Given significant variation in

the cost of care for procedures performed at U.S. institutions, these charts are not

altogether accurate. Although the charts often exaggerate the typical price of

receiving care in the United States, and possibly underestimate how much it will

cost to obtain care in India or elsewhere, they do accurately convey the point that

more affordable care can often be found beyond the borders of the United States.

CORPORATE INTEREST

Following an emphasis on marketing cosmetic surgery procedures, U.S.-based

medical brokerages next targeted individual clients seeking inexpensive health

care. They solicited customers needing hip and knee replacements, dental work,

spinal surgery, and coronary artery bypass grafts. Selling to individual retail

customers, however, is a time-consuming, inefficient way to market health

services. Though medical tourism companies continue to promote procedures to

individual customers, brokerages now target small businesses, corporations, and

health insurance companies (10). This strategy enables brokerages to signifi-

cantly increase customer volume. Their ultimate goal is to negotiate contracts

with major health insurers and large employers.

North Carolinas Blue Ridge Paper Products was the first American company

to contract with a medical brokerage and arrange overseas medical care for an

employee (17). Carl Garrett, a technician at Blue Ridge, agreed to fly to India for

surgery on his rotator cuff and gallbladder. In turn, Blue Ridge offered to cover

Garretts deductibles and travel expenses and give him a share of whatever

savings the company made by sending him to India for treatment. Just before

Garrett was to leave for India, the United Steelworkers Union publicly condemned

the plan and the company cancelled the trip. Leo Gerard, president of United

Steelworkers, argued that what began as the voluntary decision of one employee

would become mandatory as companies routinely offshored employees to

countries offering low-cost health care. Gerard argued that this shift would

both increase the risk that workers would be exposed to substandard medical careand leave them stripped of the legal protections available to patients treated in

the United States. In the face of union opposition and considerable media scrutiny,

Blue Ridge discontinued plans to outsource employee health care. Nonetheless,

other businesses now contract with medical brokerages and sell health insurance

packages incorporating out-of-country treatment options. Such companies as

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GlobalChoice Health Care, Global Health Administrators, and United Group

Programs all sell global health plans to corporate clients. In exchange for

low premiums, these plans require out-of-country care for elective procedures.

Employeesable to afford more expensive plans can receive treatmentin the United

States. Both medical tourism companies and companies selecting plans with

out-of-country treatment options argue that employees are free to choose which

plans they select. Of course, this emphasis on autonomous decision-making does

not acknowledge the severe economic constraints that can prohibit employees

from being able to afford access to care in the United States.

Arnold Milstein and Mark Smith (16) argue that small businesses are the

early adopters as the corporate sector considers the prospect of offshoring

employees health care. They suggest that if liability issues are resolved, large

corporations will incorporate outsourced health care within their benefit packages.Employees paying high premiums will be able to obtain elective surgical

procedures at U.S. medical facilities. Low budget plans will require travel to

international hospitals offering inexpensive health services. The cost of health

plans will vary depending on where health services are purchased. The rhetoric of

choice and medical consumerism will be used to promote offshore health care.

HEALTH INSURANCE COMPANIES

Medical brokerages and international hospital chains are now trying to convince

major U.S. health insurance companies to sell plans covering offshore health

care. For emergency care, customers selecting these plans will obtain treatment

at local health care facilities. For elective services, customers will have to travel

to international hospitals. Blue Cross and Blue Shield South CarolinatheSouthern Blues, as they are callednow market such a plan through the separate

company Companion Global Healthcare, whose customers can purchase plans

that include provision of health services at Bumrungrad International Hospital

in Bangkok. Hospitals and clinics in Costa Rica, India, Ireland, Singapore,

and Turkey are also included in Companion Global Healthcares network of

international hospitals and clinics. Executives at medical tourism companies and

marketing directors at international hospitals are presently attempting to sell

the offshore health care option to other major insurers.

GOVERNMENTS

Interest in offshoring the health care of Americans to international medical

facilities extends beyond the corporate sector to elected government officials.For example, in 2006, Ray Canterbury, a delegate to the state legislature of

West Virginia, proposed a House Bill that would give financial incentives

to West Virginia State employees willing to travel outside the United States for

medical care (18). If Canterburys bill is eventually passed, state employees

will have the option of traveling to India or Thailand for elective health care. The



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bill proposes to cover all travel-related expenses, eliminate co-payments and

deductibles, provide free transportation and accommodations for an accompany-

ing family member or friend, include seven supplementary sick days, and offer

employees a share of whatever savings the state gains by arranging out-of-country

care. Canterbury wants to increase competition and use the outsourcing of patients

to reduce prices at U.S. hospitals. His proposal has attracted supporters in the

West Virginia Senate. Similar legislation is tabled in Colorado. These legis-

lative initiatives have two practical goals. First, they raise the prospect that

state employees might soon have the option of having health insurance plans

that enable them to receive treatment outside the United States. Second, they

apply pressure to local health care facilities by suggesting that unless prices are

reduced, international competitors will soon start treating significant numbers

of state employees.

GLOBALIZATION OF HEALTH SERVICES

How flying from Durham to Delhi or from Charleston to Chennai for medical care

came to seem like a sensible proposition is a complicated and circuitous story.

The rising cost of health insurance premiums, job cuts, and loss of employer-

provided health insurance are key features of this narrative. A detailed exploration

of the emergence of a global market in health services would have to explore

how American medicine and health care became such massive business enter-

prises, why health care in the United States is so expensive compared with other

countries, how national economies interlocked to form a global economy, and

how biomedicine or Western medicine spread across the globe. Books such

as The Social Transformation of American Medicine (19) and Sick(20) describehow medicine in the United States came to be delivered through the market

economy. Much less well-known is how international hospitals used the doctrine

of competitive advantage to create a global market in health services. The origins

of this market can be traced to the 1997 Asian financial crisis.

Thailand

In 1997, Thailands stock market fell 75 percent and the value of Thailands

currency plummeted (21). Before July 2, 1997, it cost 25 Thai baht to buy one

U.S. dollar. By January 1998, it cost 56 baht to purchase one U.S. dollar. Investor

panic and economic turmoil rippled from Thailand to Indonesia, Malaysia, and

South Korea. From there it spread to Russia and Latin America.In the years before its economy collapsed, Thailand experienced a rapid

expansion of its middle-class population. The economic crisis erased the savings

of Thailands middle class and returned many citizens to poverty. The countrys

dramatic building boom ended, foreign capital fled Thailands economy, and

many families suffered massive financial losses. With citizens unable to afford

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private health care, for-profit hospitals in Thailand lost their customer base. Just

as they had once moved from public health care facilities to private, for-profit

institutions, many doctors and nurses left Thailands private hospitals and returned

to work at public medical facilities. During the economic crisis, several Thai

hospitals revised their marketing strategies and began targeting patients in other

countries. They solicited clients who could afford treatment and would bring

foreign currency into the country. Bumrungrad Hospital in particular succeeded

in attracting customers from Japan, Europe, the Middle East, and the United

States. Even when the financial crisis ended, Bumrungrads managers continued

expanding the hospitals international clientele. They used three strategies to

pursue this aim (22).

Taking advantage of the devalued baht and the low value of salaries and

property in Thailand, Bumrungrad executives undercut the cost of proceduresoffered at hospitals in Singapore. The marketing team placed ads in in-flight

magazines, encouraged travelers on Thai Airways to apply frequent flyer miles

toward executive physicals, and offered discount packages for surgery and other

procedures. Bumrungrad grew its clientele by using a standard sales tactic: it

beat its leading regional competitors on prices.

Next, Bumrungrad executives redesigned their hospital. They gave it the

appearance and feel of a luxury hotel. They marketed spacious private executive

suites with wireless Internet access and wide-screen televisions. They promised

free limousine pick-up service at Bangkoks International Airport and compli-

mentary visits from massage therapists. Bumrungrad executives selected the

best restaurants in Bangkok and invited their chefs to bring upscale dining to

the hospital. After a redesign of its atrium, Bumrungrad sported an Au Bon

Pain, Dairy Express, McDonalds, and Starbucks. These features had a powerful

effect on lower-income and middle-income Americans visiting Bumrungrad.

They discovered that by flying to Bangkok they could afford posh VIP services

reserved for only the wealthiest clients at private U.S. hospitals. Bumrungrads

customers offered testimonials likening the hospital to a five-star hotel. After

60 Minutes aired a clip about the hospital, Bumrungrad was bombarded with

more than 3,000 emails from Americans interested in receiving treatment there.

The institution rapidly established its standing as the leading international

hospital in a global marketplace of hospitals competing for foreign patients.

Finally, Bumrungrad executives developed a corporate philosophy promoting

customer satisfaction (22). If a patient wanted surgery and hormone therapy to

change from being male to female, Bumrungrad physicians did not introduce

obstacles by making a psychiatric evaluation part of the process. Bumrungrad brought the customer-centric philosophy of the hotel industry to the hospital

sector. With this customer-service ethic, Bumrungrad transformed itself from a

small regional hospital into an international medical center.

To executives at hospitals around the world, Bumrungrad demonstrated

that given enough incentive, price-conscious patients would travel in search of



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inexpensive health care. Surgery could be packaged with stays in ocean-front

resorts, guided tours, and evening excursions to Bangkoks street markets and

nightclub cabaret scene. Low-budget health care could be combined with the

more traditional tourist attractions of Thailand. Sun and surgery and hotels and

hospitals could be fused to create medical tourism. Bumrungrad International

now claims to provide care to more than 435,000 international patients every

year. According to Bumrungrads marketing director, 58,000 of those patients

are American. Hospital executives are building the Bumrungrad brand by con-

structing Bumrungrad Hospital Dubai in Dubai Healthcare City and establishing

Bumrungrad International Philippines.

Private equity firms and pension funds, as well as hospital executives and

senior government officials throughout Asia, noticed the increased flow of inter-

national patients traveling to Bangkok for care. They grasped that hospitalssituated in countries with low property values, low corporate taxes, low wages

for physicians, nurses, and other health care providers, advantageous currency

exchange rates, and popular tourist destinations could attract customers from

other nations. Hospital executives, government ministers, and investors in

Singapore and India were particularly influenced by Bumrungrads success in

drawing international clients.

Singapore

Before Bumrungrad and its regional competitors in Bangkok and Phuket

undercut their prices, hospitals in Singapore held the biggest share of the

international patient market in Asia. With devaluation of the baht, Singapores

hospitals could not compete for clients on the basis of price. Hospital executives

and government officials in Singapore decided they would forgo the discount

surgery market. Singapores leaders decided to boost research and development

and build on the countrys strengths as a service economy. Government ministers

and business leaders strategized to transform the city-state into a regional

biomedical hub and build a new national bioeconomy (23). They marketed

Singapores hospitals as leading destinations for well-heeled, discerning inter-

national patients interested in obtaining top-quality care rather than bargain

basement treatment.

Hospital executives and government ministers in Singapore insist that with

a population of just 4.4 million citizens, the city-state must draw international

patients to attract medical specialists, block the brain drain of health care

providers, maximize institutional efficiencies, and promote economies of scale.According to Singapores leaders, with the increased volume of international

patients traveling to Singapore, hospital revenues will climb, medical practice

will undergo more specialization, health care providers will relocate to Singapore,

costly medical equipment will become more affordable, and economic benefits

will ripple through the city-states economy (24).

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Singapore promotes medical tourism through its Singapore Medicine website.

The portal provides links to Singapores major hospital chains, particular hospitals

and clinics, international patient centers, and lists of physicians. Singapores

medical tourism strategy is working. In 2000, Singapore attracted 150,000 inter-

national patients. In 2005, 374,000 medical tourists received care in Singapore

(25, 26). By 2012, Singapore wants to attract one million international patients

every year. The Singapore Tourism Board estimates that regular tourists spend

$144 per day whereas medical tourists spend an estimated $362 (27).

Private hospital associations, government ministries, and tourism companies in

other countries learned from Bumrungrads success and Singapores coordinated

national strategy. Hospitals in Hong Kong, Indonesia, Malaysia, the Philippines,

South Korea, Taiwan, and Vietnam now promote medical tourism. Indonesia,

Malaysia, and the Philippines have national medical tourism initiatives.Building on the examples provided by Bumrungrad International and Singapores

hospital system, India is now the fastest-growing competitor in the global

health services market.

India

Private hospital chains such as Apollo, Fortis, Max Healthcare, and Wockhardt

first promoted medical tourism to India. What started as the corporate initiatives of

a few hospital chains and business entrepreneurs soon became a national economic

strategy. India now classifies care of international patients as an export product

(2830). Hospitals in India benefit from reduced tariffs on imported medical

devices such as diagnostic imaging systems, low corporate taxes, substantialgovernment investment in local transportation infrastructure and airport hubs,

and special economic zoning laws. Medical visas enable visitors from other

countries to stay in India for extended periods of treatment and recovery.

Provinces such as Goa and Kerala advertise regional medical tourism initiatives.

Hospital management teams, airline executives, private equity funds, venture

capitalists, information technology firms, and tourism agencies all support Indias

national medical tourism initiative. Extremely low wages enable private health

care facilities to provide care at prices far below rates found in other nations.

Whereas hospitals in Singapore emphasize quality of care in their marketing

campaigns, private hospitals in India compete on the basis of marketing initiatives

that emphasize both high quality care and extremely low prices.

SELLING MEDICAL TOURISM

Newspaper advertisements, call centers, hospital websites, television commer-

cials, billboards, press releases, word-of-mouth marketing, and medical broker-

ages all draw patients to private hospitals seeking international clients. The



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Internet plays a particularly important role in making hospitals accessible to an

international client base.

Hospitals selling health services to international clients assume that many

prospective clients are concerned about quality and safety of care in such coun-

tries as India and Thailand. Reservations about the quality of health services

available at international facilities are a major impediment to the emergence

of a global market in health services. To address such fears, marketing to

international customers uses various strategies to signal quality, competence,

and international standards of care.

International Hospital Accreditation

The emergence of a global market in health care generated a need for an organi-zation capable of assessing whether hospitals provide an international standard

of care. Such a body had to have widely recognized standards. Countries such

as Thailand and India have national hospital accreditation bodies. However,

hospitals wanting to proclaim themselves as international medical centers

want to be able to claim that they meet global standards. An American company

filled the gap by offering international accreditation.

The U.S.-based Joint Commission International (JCI) is now the overwhelm-

ingly dominant organization in international accreditation of hospitals. JCI

the international offshoot of The Joint Commissionhas now accredited more

than 220 health care organizations in 33 countries. To meet growing demand

for international accreditation of hospitals in the Middle East and Asia, in 2006

JCI opened regional offices in Dubai and Singapore. JCI accreditation plays a

crucial role in hospital marketing campaigns. Setting aside the question of what

JCI accreditation means in terms of assessing quality of health care and patient

safety, the labels marketing effect is to signal that an accredited hospital offers

an internationally recognized level of treatment.

Physician Training

Just as JCI accreditation is used to market hospitals, academic credentials are

used to sell the skills of particular physicians. Degrees, fellowships at elite

institutions, and U.S. board certification are all used to promote the profes-

sionalism of physicians employed by international hospitals. Websites for

hospitals in India and Thailand feature physicians trained in Australia, the

United Kingdom, and the United States. The message for customers is that the physicians who will provide their care trained at the best institutions in the

world. Hospitals seeking international patients encourage their physicians to

obtain U.S. board certification. In the absence of global standards for medical

education, U.S. board certification signals an international standard of training.

This international training and certification of health care providers plays a

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role in helping medical facilities present an image that they offer elite-level

medical care.

Building Brands

Around the world, some universities and hospitals have an international

reputation. Universities such as Harvard and Stanford are globally recognized

academic brands, just as Nike, Coca-Cola, and BMW are international corporate

brands. Countries developing their health services industry and promoting

themselves as leading destination sites for international clients are encouraging

brand-name academic institutions to build branch campuses and award prestigious

degrees to local students. Duke University, in partnership with the NationalUniversity of Singapore, runs a medical school in Singapore. Harvard Medical

International offers postgraduate training programs for health care professionals

at Dubai Healthcare City.

The establishment of North American medical schools and satellite campuses

in Asia and the Middle East serves multiple objectives. Many U.S. universities

are developing initiatives in global health; satellite campuses enable them to

expose students and faculty at their home institutions to other parts of the world.

Construction of branch campuses also happens to be extremely lucrative for

some American universities. Senior administrators of universities and medical

centers in North America recognize that the fastest-growing markets for pro-

fessional training are now in Asian nations. Duke University will receive more

than $350 million for establishing and running a medical school in Singapore

(31). Satellite campuses generate significant revenue for brand-name universities.

In turn, the training and credentials that these programs offer will probably shape

the global market for health services. Hospitals targeting international patients

will be able to advertise that their doctors and nurses are graduates of elite

academic institutions. Staff members with degrees from such programs will

bring instant cachet to hospitals targeting international clients.

Just as schools of medicine and nursing run by elite academic institutions are

being built in Asia and the Middle East, hospitals in these regions are cultivating

partnerships with brand-name medical centers. Johns Hopkins Medicine Inter-

national is affiliated with Indias Apollo Hospitals and operates a clinic in

Singapore. Harvard Medical International is part of Dubai Healthcare City, affili-

ated with Indias Wockhardt Hospital chain, and runs several hospitals in

China. The Mayo Clinic is a participant in Dubai Healthcare City. ClevelandClinic Abu Dhabi is presently under construction.

Co-branding initiatives play major roles in international marketing campaigns.

The Harvard name is on Wockhardt hospitals throughout India. Partnerships

with elite organizations such as Harvard, Johns Hopkins, and the Mayo Clinic

confer instant status and brand-name recognition. They act as customer magnets



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by sending signals about quality of care and selling the promise of world-class

treatment at prices well below rates in the United States.

Technology in the International Marketplace

Just as international accreditation, training at elite institutions, and partnering

with global brands are used to sell health services on the global market, symbols

of advanced biomedical technologies convey the message that hospitals offer

top-tier health care. Bangkok Hospital advertises itself as the only hospital in

Thailand with a gamma knife for neurosurgery. Apollo Hospitals promotes its

advanced diagnostic imaging suites. These icons of modern medical care enable

hospitals to provide specialized services. They permit health care providers to

perform procedures for which hospitals in the United States and other coun-

tries charge high rates. In addition, they project an image of hospitals in India,

Singapore, and Thailand as participants in a global biomedical economy of

advanced, specialized, elite, acute care hospital facilities.

Private hospitals around the world want to attract customers from the United

States and other countries. Medical brokerages profit whenever they sell their

services to clients. Many U.S. companies see outsourcing of health services

for employees as an effective way of cutting costs. Various parties have a clear

economic interest in promoting globalization of health services. Whatever the

benefits of offshoring medical care, the establishment of a global market in

health services will have profound consequences for patients, the practice of

medicine, and the delivery of health care. Advantages of international health-

related travel are widely advertised. In contrast, little consideration is given tohow globalization of health services will transformpossibly for the worsethe

practice of medicine, the experience of receiving care, and the organization

of health systems. These concerns are scarcely matters that medical tourism

companies and international hospitals want to address at trade shows, congresses,

and other promotional events.

PATIENT SAFETY

International hospitals emphasize the high quality of the care they offer. Adver-

tising copy commonly asserts that destination hospitals meet or exceed standards

for patient safety and quality of care in the United States. Some hospitals draw

attention to the many reports on medical error and adverse medical events at

U.S. health care facilities. They use these findings to argue that U.S. patientswill receive better, safer care if they leave the United States for treatment.

In turn, U.S. organizations such as the American Medical Association and

American Hospital Association express concerns about medical tourism and

quality of care at international hospitals. The lack of comparative data from

medical facilities around the world makes it impossible to assess patient safety

456 / Turner


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and quality of care at leading destination sites for international patient travel.

The U.S. Centers for Disease Control and Prevention has published reports about

substandard care experienced by patients who underwent cosmetic surgery at

clinics in the Dominican Republic and Venezuela (32, 33). Australia issued a

travel advisory urging its citizens to avoid treatment at unlicensed cosmetic

surgery clinics in Thailand. A website, www.bumrungraddeath.com, accuses

Bumrungrad International Hospital of providing negligent care to an American

patient who died while receiving treatment there. These reports raise concerns

but do not provide sufficient evidence with which to make broad judgments

about patient safety when individuals travel in search of affordable health care.

Thus, despite grounds for concern about quality of care and patient safety in

the global health services marketplace, there is limited evidence with which to

judge the quality of medical care around the world. With cosmetic surgerysometimes performed by unlicensed practitioners in unaccredited facilities, of all

individuals traveling for health care, cosmetic surgery patients are perhaps at

greatest risk when they travel for inexpensive surgery. Quality of care might be

less of an issue at leading destination sites for medical tourism. These institutions

have a powerful long-term economic interest in providing high-quality health

services. Of course, the profit imperative could also undermine quality of care

with its pressure to minimize costs and maximize returns.

Whatever the actual risks of receiving substandard care at bargain-priced

international health care destinations, hospitals in India and elsewhere make

dramatic claims about quality of care and patient safety. Without publishing

data in peer-reviewed journals or subjecting their claims to critical scrutiny,

they purport to offer care that is both less expensive and higher quality than

that found in leading U.S. health care facilities. Though these claims might

be accurate, they have never been tested and verified by independent parties.

Journalists and health researchers attempting to investigate the development of a

global marketplace in health services need to realize that outcomes data on

quality of care and patient safety should be regarded as advertising copy rather

than as reliable, peer-reviewed claims about mortality and morbidity rates. Inter-

national health care facilities do not publish data on medical errors, hospital

infection rates, or adverse events. Very little evidence is available with which to

compare quality of care at health care facilities around the world. Claims about

patient safety and quality of care are used to promote health care facilities and

reassure potential customers that inexpensive medical care is also high-quality

care. Until these claims are subjected to serious critical scrutiny, they should

be regarded simply as components of broader marketing initiatives. Healthresearchers who uncritically reproduce these claims fail to realize how they are

advancing the economic interests of the very institutions they are supposedly

subjecting to scholarly analysis.

Serious efforts to set high standards for international accreditation could play

a valuable role in promoting access to reliable, publicly accessible information on



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patient safety and quality of care at international health care facilities. Independent

analysis by an accreditation body able to withstand regulatory capture by the

institutions it purports to evaluate could bring greater transparency to the quality

of care at health care facilities around the world. At present, international patients

can comparison-shop on the basis of price. They have no reliable way of com-

paring the safety and quality of care they are likely to receive at international

facilities. Improving the quality of information available within the global health

care marketplace would require major changes to processes of international

hospital accreditation.

CONTINUITY OF CARE

Continuity of care is another problem with efforts by U.S. patients to findaffordable health care in the global marketplace. The medical tourism industry

uses a procedure-driven approach to delivering health care. Discrete procedures

are assigned an economic value and then marketed to international patients. The

procedure-driven approach advertises treatment as a singular event. Prospective

customers are attracted by low prices for hip procedures, cardiac procedures, and

other interventions. This narrow framing of health care delivery emphasizes

surgical interventions and promotes an understanding of health care based on

specific tasks that can be assigned economic values. Obscured in this account

is the extent to which health care occurs as a continuum over time. A less

procedure-driven account of health care would recognize the importance of

care extending from early conversations about a patients ailments to long-term

recovery from illness or injury. Characterizing health care as medical procedures

performed in discrete episodes of treatment conceals the many interactions that

should occur before provision of specific treatments. In some instances, with

better communication and preventive care, the continuum of care need not include

surgical intervention. In addition, the focus of medical tourism companies and

international health care facilities on promoting particular procedures obscures

the level of care patients require following orthopedic surgery, cardiac surgery,

and other procedures. Because of the episodic nature of interventions sold in

the global health services marketplace, continuity of care is a serious problem.

Surgical treatment dominates how treatment is promoted, and the need for care

both before and after surgery is neglected. While some patients return home

with medical records and an after care plan, others return to the United States

with no medical documentation, no follow-up treatment plan, and no ready means

of gaining access to local health care providers. Viewed across a sufficientlylarge patient population, this procedure-driven, discontinuous model of health

care is likely to have significant consequences. Having obtained care at a facility

in another country, some U.S. patients are likely to return home and have non-

existent or inadequate long-term care. Though some medical tourism companies

make arrangements for follow-up care with local health care providers, the

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procedure-driven way in which the medical tourism industry frames health care

poses a major challenge to the notion that health care delivery occurs along a

continuum and that all phases of treatment can have a significant effect on

patients health. Few medical tourism companies currently describe how they

propose to assist patients who require costly care and follow-up treatment after

their return to the United States.

Patient safety is the most publicized concern with medical tourism. However,

the most significant long-term consequences of a global market in health services

are related to the worldwide establishment of medicine as a profit-driven business

enterprise. Medical tourism represents the full integration of medicine with

global capitalism. Ability to pay determines access to care; the more customers

are prepared to pay, the more services they can purchase. Add-ons such

as stays in luxury hotels and exclusive tourist resorts are determined by howmuch customers are prepared to pay. In turn, limited economic resources buy

limited care.

FROM COVENANT TO CONTRACT

Describing his fathers preDepression era medical practice in Flushing, New

York, Lewis Thomas (34) captures a period before American medicine was

fully integrated into the market economy. In The Youngest Science: Notes of

a Medicine-Watcher, Thomas describes a time of small-town physicians, the

doctors office next to the living room in the family home, house calls, and an

unstated sense of duty that included treating patients regardless of their ability

to pay. Thomas sketches what medicine in the United States was like before

the spread of managed care organizations, hospital marketing campaigns, and

medical debt-collection agencies. Noting the often shaky financial status of his

fathers practice, Thomas writes (34):

Very few of the patients paid promptly, and a good many never paid at all.

Some sent in small checks, once every few months. . . . These were the years

everyone thinks of as the good times for the country, the ten years before the

Great Depression. The town was prosperous, but the practice of medicine was

accepted to be a chancy way to make a living, and nobody expected a doctor

to get rich, least of all the doctors themselves. In the town where I grew up,

there were two or three physicians whose families seemed rich, but the money

was old family money, not income from practice; the rest of my fathers

colleagues lived from month to month on whatever cash their patients

provided and did a lot of their work free; not that they wanted to or felt anyconscious sense of charity, but because that was the way it was.

Sixty years after the era Thomas describes, William May (35) used the phrase

the physicians covenant to describe the moral bonds connecting doctors and

patients and making medicine more than a service available for purchase in the



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marketplace. In The Physicians Covenant: Images of the Healer in Medical

Ethics, May articulates an understanding of medicine in which ties between

physicians and patients differ from the contractual relations between buyers and

sellers of goods or services. May describes powerful, quasi-religious bonds of

trust and moral commitment connecting patients to physicians. For May, the

intimacy of medicine, the involvement of doctors in the personal lives of their

patients, the role of the physician in birth, the life course, and death, and the special

moral obligations of doctors toward patientsall infuse the practice of medicine

with moral gravitas and a sense of duty. For some contemporary doctors, the

practice of medicine retains this dimension. To them, being a doctor involves far

more than just providing a service in exchange for remuneration. For other patients

and physicians, the notion of medicine as calling, vocation, or form of community

service survives more as nostalgia for a dimly remembered past than as con-temporary experience. In contrast to the 1920s, 21st century American health

care is delivered in a market-driven bureaucratized economy.

Managed care organizations control costs and carefully monitor the corporate

bottom line. Investors in private hospital chains and clinics want managers to

maximize their return on investment by reducing costs, increasing earnings, and

providing treatment to paying customers. Hospitals boost revenues by advertising

for customers, marketing high-margin procedures, and refusing to cross-subsidize

care for patients who cannot afford treatment. Focused health care factories

specialize in doing shoulder operations or hernia repairs and maximize profits by

increasing patient volume and reducing time to complete procedures. Manage-

ment teams bring efficiency-optimizing techniques from the factory floor to the

hospital floor. Private hospitals hire hotel managers to improve customer service.

Hospital chains run much like other large corporations. Medicine, and more

broadly health care, is embedded within a larger service-oriented, bureaucratized,

profit-driven market economy.

With the shift away from covenantal relations to contracts between buyers and

sellers, standard market mechanisms come into effect. Vendors try to maximize

their economic returns and control the risk of economic loss by marketing profit-

able procedures and limiting or eliminating less lucrative forms of health care

delivery. They use commonplace advertising techniques to increase market share.

Hospitals compete for patients, avoid patients that will harm their economic

bottom lines, and attempt to build their brands and control costs while maxi-

mizing revenues (36). In turn, patients, relabeled as customers or medical

consumers, want the best possible services at the lowest possible prices. With no

special moral ties connecting patients to doctors, patients paying out-of-pocketfor care comparison-shop and go where they can get the lowest prices on services.

In a global economy in health services, the lowest prices for health care are

typically not found at U.S. hospitals. Customers with limited financial resources

are compelled to offshore themselves to get affordable treatment (11, 37).

Price-conscious consumers travel from Durham to Delhi and Boston to Bangalore

460 / Turner


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to get the best deals for health services. Bound by moral covenants, patients and

physicians are connected by ties that are not reducible to market transactions.

Brought together through contractual relations, patients relate to doctors as buyers

to sellers. The notion of a covenant binding physicians to patients makes little

sense in an economic context in which patients select health care facilities on the

basis of price, travel to countries to which they have no ties, receive services from

physicians with whom they have no prior relationship, and then leave after

receiving the services they purchased. Buying medical interventions becomes

much like buying other services in the global marketplace.

THE CUSTOMER IS ALWAYS RIGHT

The integration of health services with the global marketplace is connected to aradical shift in the internal morality of medicine. In more traditional models of the

patient-physician relationship, the ancient maxim primum non nocere, first, do

no harm, is supposed to guide the practice of medicine. According to this norm,

physicians must exercise clinical judgment when deciding whether a treatment is

medically indicated. In service-based market transactions, the guiding principle

of business is the customer is always right. Clients rather than vendors should

decide what they will purchase. Satisfying customer preferences played an

important part in making Bumrungrad a leading destination site for international

patients. Such a philosophy, embedded as a core norm in the global delivery of

health services, is reshaping the practice of medicine. Satisfying customers

desires is different from respecting the internal morality of a profession guided by

norms of beneficence, nonmaleficence, and clinical judgments about what care

is warranted. A global health services market will enable some patients to obtainmedical care that they could not afford to purchase in their local communities.

It will probably also contribute to the spread of a consumerist ethos in which

health care providers serve the needs of customers, rather than respecting

medicine as a practice with internal normative standards. Generating earnings

rather than practicing medicine according to an internal professional morality

that emphasizes promoting health and avoiding harm plays a part in the global

marketing of procedures such as commercial organ transplants and stem cell

injections with unknown contents and no demonstrated therapeutic benefits.

CONTRACTS AND CAVEAT EMPTOR

In the United States, physicians have legal obligations to disclose risks, benefits,

alternatives to treatment, and consequences of non-treatment. The concept ofinformed consent is in part based on this moral and legal duty. In the global

marketplace, contracts tie customers to providers of health services. In

marketplace transactions governed by contracts, vendors have obligations to

purchasers, but much greater emphasis is placed on the responsibility of buyers

to exercise diligence when making purchases. Medical brokerages state that they



20/25

merely facilitate or coordinate health care services. They assume no legal

liability in the event of adverse events, medical error, negligence, or medical

malpractice. Visitors to medical brokerage websites are told that customers choose

where to obtain medical care, what procedures to purchase, and whom to select as

a physician. Clients are told to do their homework before purchasing health

services. Before customers sign contracts with medical brokerages, they sign

waiver-of-liability forms. These documents are designed to shield brokerages

from legal action if their clients suffer harm when obtaining treatment abroad.

Countries such as India, the Philippines, and Thailand are not known for strong

regulatory oversight mechanisms in the field of health care (38). Physicians in

these settings typically pay low rates for medical malpractice insurance. Plaintiffs

rarely receive significant settlements even if malpractice or negligence is estab-

lished. Many cases never work their way through complex, backlogged bureauc-racies. There is a global market in health care services, but no accompanying

transnational legal infrastructure governing the international sale of health

services. Buyer beware accurately captures a global economy in which

customers often find they are unable to obtain redress when they are harmed

while being treated. The global health services marketplace functions with few

transnational safety nets or protective mechanisms in place.

COMMUNICATION

The profits to be gained from selling medical services in the global marketplace

are likely to shape social interaction with customers. Medical tourism companies

are in the business of selling health care. Sales representatives at automobile

dealerships do not encourage customers to consider walking to work, riding a

bicycle, or buying a subway pass before considering purchase of a vehicle.

Medical tourism companies are the car dealerships of the global health services

industry. They exist to sell health services in volume. They are not bound by

an enforceable code of ethics, legislation governing health professionals, or

the fiduciary duties of physicians. The profit imperative is likely to shape how

they disclose information to customers. To boost sales, company representatives

will be inclined to exaggerate benefits, minimize risks, leave unmentioned any

alternatives to treatment, and accommodate customers preferences. Earnings

come from selling services rather than from serving the best interests of patients.

With this emphasis on selling procedures, some travelers will fly to international

health care facilities and receive medically unnecessary care.

In marketplace transactions where destination hospitals have made substantialinvestments to attract international clients, both medical tourism companies and

international hospitals want to boost sales. Government officials want to reap

returns from investment of tax dollars in the medical tourism industry. Bonds of

neighborliness, duty, and community will not temper these market transactions.

Business interests are likely to have a significant effect on what information is

462 / Turner


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communicated to clients. The cumulative framing effect is to sell medical pro-

cedures rather than to carefully assess whether particular medical interventions

are truly necessary.

PUBLICLY FUNDED HEALTH CARE AND GLOBAL

PRIVATIZATION OF HEALTH SERVICES

News media coverage of medical tourism commonly addresses risks related to

obtaining treatment abroad. This orientation toward the interests of the traveling

patient overlooks how global privatization of health services risks undermining

local access to health care. Private, for-profit hospitals in India, Thailand, and

other nations sell services to foreign patients, expatriates, and local economicelites. They do not provide health care to local citizens with minimal economic

resources. Rather, they maximize profits and offer better rates than competitor

hospitals by refusing to cross-subsidize care. Maximum earnings are achieved by

selling high-margin procedures to patients able to pay out-of-pocket for treatment.

These hospitals do not profit by offering inexpensive low-technology care or by

treating patients who need care but cannot afford to pay for treatment.

Privatization of health services in countries such as India and Thailand does

not simply put access to affordable health care beyond the reach of local patients.

It also undermines publicly funded health care facilities. With higher salaries

in private hospitals catering to medical tourists, public health care facilities in

Thailand and elsewhere have difficulty retaining health care providers. Brain

drain occurs from publicly funded hospitals to private medical centers (39).

As doctors and nurses leave public institutions, the differences between public

hospitals and private institutions are magnified. Public hospitals become the

health care destination of last resort even for low-income patients who cannot

afford treatment at for-profit private hospitals. Promotion of medical tourism in

such countries as India and Thailand is likely to undermine national efforts to

improve health equity. For-profit hospitals maximize profits by ignoring the

low-income populations that surround them. Public health care facilities are

hollowed as health care professionals move to private, for-profit facilities. Paying

international patients rather than ill individuals from local communities become

the preferred clientele.

Thus, as the global spread of for-profit health centers benefits customers with

the financial resources to purchase care, it risks harming low-income patients

by undermining public access to affordable care and pulling health care providersfrom the public sector into private facilities. The rise of medical tourism is

related to the global spread of a form of capitalism that tolerates striking inequal-

ities in income and health. Hospitals that challenge this trend by providing

subsidized care to low-income patients risk becoming less competitive by

increasing the cost of treatment for wealthier customers.



22/25

PROMOTING THE DEVELOPMENT OF A GLOBAL

MARKETPLACE IN HEALTH SERVICES

Despite the lack of serious efforts to explore the risks and harms related to the

rise of the medical tourism industry, multiple parties are contributing to the

expansion of a global marketplace in health services. Individual institutions

such as Bumrungrad International see an opportunity to expand the number

of international patients purchasing health care in Bangkok. Medical tourism

companies and medical tourism associations use assorted marketing strategies to

promote, routinize, and normalize obtaining health care at international facilities.

Private hospitals band together to form networks and associations, and these

collectives are then marketed to international patients. National and regional

governments in such countries as India, the Philippines, Singapore, and Thailandare taking steps to build bioeconomies and transform themselves into medical

hubs for patients from around the world.

At the international level, the World Bank is an ideological and financial

proponent of helping medical facilities in low-income nations use the doctrine of

competitive advantage to increase their market share of international patients.

World Bank economists have challenged the discriminatory effect of existing

forms of health insurance and used economic analysis to argue that patients should

be able to use portable health insurance to obtain health care at destinations

around the world. The World Bank has also played an important role in bringing

together executives from international health care facilities and providing them

with venues for discussing how to move patient care into the global marketplace.

The World Trade Organization has also participated in creating architecture

for a global marketplace in health services. The general mandate of the World

Trade Organization is to eliminate barriers to trade and promote the spread

of global markets, and it has had an important role in demarcating the various

ways in which health services can be traded across borders.

Multiple social actors are deeply engaged in promoting the expansion of a

globally integrated marketplace in health services. Most of these organizations

stand to profit from further privatizing heath care and promoting mass movement

of patients into the international marketplace. In this atmosphere of enthusiasm

for pushing delivery of health care into the global marketplace, little consideration

is given to how the rise of the medical tourism industry might harm patients,

damage publicly funded health care systems and reduce local access to care in

destination nations, and alter the fabric of health care delivery in countries from

which patients are leaving in search of affordable health care. Subject to massivemarketing efforts, medical tourism and the globalization of health services

has been subjected to little serious, critical academic scrutiny. Despite a wide-

spread failure to consider dangers associated with the emergence of a global

marketplace in health services, patients are traveling the world in search of

affordable medical interventions. The consequences of this development are as

464 / Turner


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yet unclear. Nonetheless, it is evident that the marketing of medical tourism has

leapt far ahead of the development of legal protections for international patients.

CONCLUSION

The percentage of the U.S. population lacking health insurance is growing. Denial

of claims, exclusion of preexisting conditions, high premiums and co-payments,

and accumulation of medical debt further reduce access to care. As premiums for

health insurance climb, jobs in manufacturing and service industries are moving

to countries where labor costs are lower than in the United States. Employees

who keep their jobs often must surrender health benefits in negotiation with

company management. As employees find their health benefits reduced, nonprofit

safety net hospitals are trying to reposition themselves and reduce their exposureto patients lacking health insurance and unable to pay out-of-pocket for care.

At the top of the U.S. economic pyramid, the countrys elite remain able to

purchase health care at American medical facilities. Lower-income and middle-

class individuals increasingly struggle to afford the cost of health care in the

United States. Thoroughly enmeshed in the larger market economy, U.S. health

care now takes the form of other service industries. It defers to customer prefer-

ences, is sold through standard marketing techniques, and is available for purchase

to those consumers with sufficient economic resources. Older notions of the

physicians covenant have little place in such a market-driven health service

industry. Secularized, stripped of any special meaning, diminished to just another

service available for purchase in the marketplace, and with personal ties to

patients replaced by impersonal interactions inside large bureaucracies, hospitals

must now compete for customers in the global health service economy. Wealthycustomers are still able to afford health care in the United States. Lower-income

and middle-class Americans increasingly find themselves traveling to offshore

hospitals offering health services at discount prices. With the physicians covenant

but a faint memory, and the nations social safety nets badly frayed through

years of cutbacks and cost-containment strategies, the age of global comparison

shopping for health services has arrived.

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Direct reprint requests to:

Leigh Turner

Center for Bioethics

University of MinnesotaN504 Boynton, 410 Church Street SE

Minneapolis, MN 55455

[email protected]


Documents

Leigh Turner IJHS 2010